A client at 40-weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive. Which actions should the nurse plan to perform? (Select all that apply.)

Place client in a negative pressure room

Implement droplet precautions

Encourage the mother to bottle-feed

Give antiviral medication intravenously

Use standard precautions

Answer and Explanation

Correct Answer : C,D,E

A. Place client in a negative pressure room: HIV is not an airborne disease, and clients with HIV do not require isolation in a negative pressure room. Standard precautions are sufficient to prevent transmission.

B. Implement droplet precautions: HIV is not transmitted via droplets. It is transmitted through contact with blood, certain body fluids, or perinatal exposure. Droplet precautions are not indicated.

C. Encourage the mother to bottle-feed: HIV can be transmitted through breast milk. To prevent vertical transmission postpartum, mothers with HIV are advised to avoid breastfeeding and to use formula or bottle-feed instead.

D. Give antiviral medication intravenously: Intrapartum IV zidovudine should be administered in the following situations: (a) HIV RNA >1,000 copies/mL, (b) unknown HIV RNA, (c) known or suspected lack of adherence since the last HIV RNA result, or (d) a positive expedited antigen/antibody HIV test result during labor (AI).

E. Use standard precautions: Standard precautions are the appropriate infection control measures for caring for clients with HIV. This includes wearing gloves, practicing proper hand hygiene, and avoiding contact with the client's blood and other potentially infectious fluids.

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Correct Answer is C

Explanation

Explain reasons consent for an infant autopsy is needed:
Autopsy might be necessary for understanding the cause of fetal demise, providing answers to the parents, and helping future pregnancies. However, it's not the most immediate or essential action in this scenario.

Determine if the mother desires a visit from her clergy:
Spiritual and emotional support is crucial during this distressing time. While clergy support is valuable, it's not the most urgent action needed immediately after delivery.

Encourage the mother to hold and spend time with her baby:
This is a crucial part of the grieving process and helps in acknowledging and creating memories with the baby. It's an essential step in providing emotional support to the mother.

Create a memory box of baby's footprints and photographs:
This is also a critical step in assisting the parents with the grieving process. It helps in cherishing the memories and creating keepsakes that may provide comfort in the future.

A. Strawberries B. Collard greens. C. Whole milk D. Yogurt

Correct Answer is A

Explanation

A. Strawberries:
Strawberries contain a moderate amount of folic acid, providing a good alternative source for the client. While not as high as some vegetables, they still offer a reasonable amount of this essential nutrient. This could be a suitable option considering the client's dislike for green leafy vegetables and allergy to soy.

B. Collard greens:
Collard greens are an excellent source of folic acid. However, since the client dislikes green leafy vegetables, recommending collard greens might not align with her preferences.

C. Whole milk:
Whole milk doesn't contain significant amounts of folic acid. While it's a source of other nutrients, it isn't a primary choice for obtaining folic acid.

D. Yogurt:
Similar to whole milk, yogurt doesn't contain a substantial amount of folic acid. While it offers various health benefits due to its probiotics and nutrients, it's not a significant source of folic acid.

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A client at 40-weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive. Which actions should the nurse plan to perform? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures Which action is most important for the nurse to take?

Correct Answer is C

Explanation

After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?

Correct Answer is A

Explanation

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